Random thoughts from a few cantankerous American physicians. All contributors are board certified. Various specialties are represented here. I do not know where this will lead but hope it will at least be an enjoyable read. All of the names mentioned in this blog are pseudonyms, the ages have been changed, and in half the cases the gender as well. All photographs are published with patient consent or are digitally altered to preserve anonymity. Trust us, we're doctors.

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Wednesday, April 02, 2008

This actually links up with the prior post. I just don't want it to get buried and not read.

This for the "Anon" everyone is bashing...

I'm going to assume that you are a good person and what you have experienced is fact. In light of that, read on...

The last time I "believed" what a patient told me (and that is probably not the right way to put it, but it works perfectly for your post) was a year or so ago. Please read on.

One of my OWN ED NURSES, late 30's, came in with RLQ abdominal pain. Insisted it was a kidney stone (she had had one before) and only wanted Toradol for pain. She told me there was "no way" she could be pregnant (as in abstinence). So I believed her. Surely I could believe one of my own nurses. So I did NOT order a pregnancy test. I did the renal stone CT, which was negative, and treated her as a recently passed kidney stone( some blood in her urine). I only told her to take Ibuprofen for pain which was just fine with her, as in not SEEKING drugs.

Two weeks later she came back for continued pain, worsened. And guess what?! She was pregnant and had a fucking ruptured ECTOPIC pregnancy with a hemoglobin of 8! Thank God she #1)loves me #2) remembers she told me there was NO WAY she could be pregnant, so I won't be sued... (Oh yeah, also in last year had a 54 yr old woman who had had a tubal ligation come in with belly pain and have a POSITIVE pregnancy test!).

So take your fucking size 2 ass somewhere else with with your complaints about how we should believe you or anybody else about ANYTHING they say in the ED, got it? It's up to us to decided whether you have a serious illness that might kill you, NOT YOU!!

33 comments:

I'm not in health care (I'm a HS teacher) but I think your thoughts on believing / not believing patients are widely applicable to a lot of different walks of life. For example, if I get 50 papers turned in, and 1 turns out to be plagiarized, do I focus on the 49 decent ones? Nope, I rant and bitch about the other one. If I visit a restaurant and get great service three times in a row and then horrible service the fourth, do I think of it as a great place? Nope. Same with medicine, only more so because of the greatly increased risks. It is human nature to want to avoid getting burned again - especially when believing someone and "getting burned" could result in, y'know, death or a lawsuit. So of COURSE you don't believe patients. I wouldn't either if I were in medicine. People suck!

And BTW I hold ER staff in high regard - we've been there a few times and have always been treated with care and respect. I hope we deserved it - I know we tried to and will continue to try to in the future. Thanks to all of you who work there on a daily basis.

You know, anytime I need a meidcal *something* whatever that may be, I always take a preg test, if offered, just to make sure. The last thing I need is a problem with a pregnancy, planned or not, to give me guilt and harm a little one.

I try to stay out of internet drama because it confuses me and just makes my head spin. I don't even know what this is in reference to, but holy hell...I laughed SO hard at this:"So take your fucking size 2 ass somewhere else..."

There are some behaviors that automatically raise suspicions about the trustworthiness of what a patient is saying. The adamant refusal to take a pregnancy test would suggest that there is something to hide there, raise suspicion about what it is that the person is hiding, and suggest that all relevant screening be very thorough.

While I do not have a uterus and am blissfully unaware of the joys of pregnancy, I know many people of the uterine endowed persuasion, and some of them have become pregnant. They have had a variety of presentations. Some could state that they thought they were pregnant, because of repetition of a symptom that they had when pregnant before. Please tell me, what symptoms tell you that you are not pregnant? Only the truly gullible believe in abstinence. Being a size 2 has nothing to do with being able to tell that you are not pregnant, since there is no "not pregnant" symptom - except for being a guy, and doctors and nurses usually catch on to that symptom. :-)

Never understood why the pregnancy test is such an insult. I got one on a nun once. She was there for a knee scope, quite attractive actually, and we didn't roll back to the OR till it came back negatorie.

S.O.P. in the O.R. Any woman of childbearing age gets no surgery until the HCG comes back. If it's positive it doesn't necessarily mean no surgery, but some things need to be adjusted for the baby's protection.

Taught myself a lesson the other day in the ER (I'm an MSIV going into IM) - had a pt w 5d hx n/v/d - resolving n/v but continued diarrhea. I specifically ask smoking/drinking hx - "never smoked, but have an occasional glass of wine" she says. "Let's get belly labs, just for grins and giggles" says attending (I'm thinking resolving gastroenteritis as primary ddx).

When her lipase returns at 4200, the attending's comment was "are the labs lying, or do we need to redefine "occasional glass of wine"????"

--- I will NEVER "believe" pts again - I will double check everything positive.

The scariest thing I've ever read in this blog is that a 50-something year old woman who had had a tubal ligation was pregnant! I got that done right after my seventh baby, and felt perfectly safe from pregnancy thereafter and now you're saying it can happen?????? How on earth? Tubes severed, how could the eggs make it down?

Just don't get too comfortable with the U preg. I had a hell of a case, should probably write it up. young gil wither her parents who had been to the children's hospital(where I also work) for back pain, got a uHCG(neg) sent home with motrin. Now back c severe pain, fever, a few white cells in the urine but back pain so bad that she couldn't walk(L-spine not CVA). upreg negative, other labs normal. MRI L-spine to R/O discitis, radiolgy calls me with the wonderful news that this gal has a bun in the oven. Serum HCG > 100,000. Of course I had to look this up and did find a handful of similar reports with no explanation. Oh nother Upreg was then positive when she went to the OB the next day.

My question is, why didn't Anon (who added another star to this highly entertaining thread) complain about the treatment she received to her OWN physician, nurse, ED, and hospital? Why take it out on the good folks at M.D.O.D.? Also, what does the fact that you have an "advanced degree and bathe regularly" have to do with anything? Lots of users and abusers fit in that same category.

Maybe she's Dr. Debra Peel (in cognito -- but not really).

Anon, have some chocolate and get back to me when you're a 57 YOF living with a broken humerus for 6 months in a rural village in a developing country with a "sling" as your only means of "relief." Hers must've been a comparatively bearable pain to that of your gallbladder. No Toradol, let alone Tylenol in sight...

let's be careful not to perpetuate a myth here. the upreg is sensitive down to a serum quant of 25 - 50. not 25000 to 50000 but 25 to 50. so, a very dilute urine might, just might, be negative in a pregnant patient, but i suggest what happened to your patient is lab error. patients are convinced the serum pregnancy test is more accurate than the urine and this is not true. the serum quant is more helpful re dates but much more expensive, the serum qualitative is essentially the same test as the urine qualitative.

Not having had any since I turned 50(not by choice, I've always been mean and ugly, but when old got in the mix, sperm donors vanished) and being spayed at 40, it wouldn't bother me a bit to be asked for a pregnancy test. Kinda like being carded at the beer and wine store. Oh, and there is the fact that if I was in pain and wanted help, I would want to be cooperative. Being clean and educated, I can both pour piss out of a boot and piss in a cup. Just don't see anon's problem. Maybe size 6 head not fitting comfortably up that size 2 ass? Anyway, thanks for ALL that you do and the funny reporting.

Can anyone explain to me what the previous commenter meant when he suggested that a high lipase is proof of more than the occasional glass of wine? Is it not possible for humans to have elevated lipase due to, say, idiopathic necrotizing pancreatitis that is unrelated to alcohol intake? Or from a viral infection like one of the hepatitis viruses? Or due to hypertriglyceridemia or even pancreatic tumors? I see elevated lipase for all these reasons in my animal patients and no one is suggesting that either the labs are lying or someone is giving the pets alcohol....

It isn't about believing or not believing. It is necessary medical care. The 19th century Brittish physicians had a little two-part aphorism by which they required all their medical students to abide: "1. The reproductive age female is pregnant, until proven otherwise. 2. The pregnancy is ectopic, until proven otherwise." That is still not such a bad clinical pearl, even now in the 21st century.

Annonymous, it is not an insult to acknowllege that women become pregnant. Some of us think that this is an entirely honorable thing. I also have to tell you (and I truely do not mean to upset you by telling you this) but after 25 years as a registered nurse I have learned that there are three areas in the patient history that cannot be relied on, and they are the patients answers to questions related to sex, drugs, and alcohol. Today, tobacco use is also so stigmatized that patients often conceal it. Please don't get angry. This is not an insult, its just an honest appreciation of human nature. IT IS NOT PERSONNAL! We just have this wacky thing about not letting our patients die horrible, agonizing deaths while we are taking care of them, which is what can happen if you fail to catch an early ectopic pregnancy. Were just funny that way.

Just an interesting thought. The Wal-mart brand Equate pregnancy test is more accurate than one you can get in your doctor's office. I have known people to get a positive on it then go get a HCGq which was 5. For me I got positives at 5 dpo and 7 dpo with two different kiddos. My ob's office test showed me negative both times.

Really though, you should check out this test:

How about a USB pregnancy test? You seriously hook the thing up to your USB and it uses the computer juice to electrophorese your pee. Then you get a numerical readout in a windows format. Who needs a quant from their doctor anymore? For $18, you get 20 strips. That's so much cheaper than a visit to the doc and a lab test.

On asking one of my supervisors if he thought the patient was faking he responded... Don't you watch House? Everybody's lying.Well put, thanks for blogging and giving us a taste of what real medicine is.

I love you. I'm so glad I found your blog. I am a family physician that was on the brink of a nervous breakdown dealing with these crackhead patients, until now. My co-worker (M.D.) and I read your blogs in-between patients.

Thank you kindly Jeanette,God bless you for hanging in. Few of us who wrote the meat of this blog are still in "the show". And when you find yourself wondering if there's something wrong with you for being frustrated with medicine today then know it simply mean you have not surrendered your skills of discernment. Now go get Botox training and GTFO. ;)